Tracheal rupture developing after blunt thoracic trauma

doi:10.4236/crcm.2013.29131

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Vol.2, No.9, 502-504 (2013) Case Reports in Clinical Medicine

http://dx.doi.org/10.4236/crcm.2013.29131

Tracheal rupture developing after blunt thoracic

trauma

Hasan Kara*, Aysegul Bayir, Ahmet Ak, Necmettin Tufekci, Selim Degirmenci, Murat Akinci

Department of Emergency Medicine, Faculty of Medicine, Selçuk University, Konya, Turkey;

*Corresponding Author: [email protected]

Received 17 October 2013; revised 17 November 2013; accepted 7 December 2013

which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. In accor-

ABSTRACT

Tracheal and bronchial injuries are life-threat-

ening traumas that usually develop after traffic

accidents or a fall from heights. The most com-

mon cause is motor vehicle accidents. Trache-

obronchial injuries develop in 1% - 2% of blunt

thoracic traumas. The mortality rate is 30% in

these patients and deaths usually occur within

the first hours. Sixty five percent of surviving

patients are diagnosed in later periods where

complications are frequent. In conclusion, clini-

cal evaluation and diagnostic tests should be

performed immediately and carefully. In this

study, a patient who developed tracheal rupture

after blunt cervical and thoracic trauma was pre-

sented.

Keyw ords: Blunt Cervical Traum a; Blunt Thoracic

Trauma; Tracheal Rupture

1. INTRODUCTION

Tracheal and bronchial injuries usually develop as the

result of traffic accidents, a fall from heights, being

crushed, stab wounds or gunshot wounds. Tracheobron-

chial injuries may also develop due to elevated intratho-

racic pressure and rib fractures during cardiopulmonary

resuscitation. Tracheobronchial injuries develop in 1% -

2% of thoracic traumas. Approximately, 15% - 27% of

tracheobronchial injuries are tracheal ruptures which

have high morbidity and mortality rates [1]. Because of

the protective surrounding structures, mobility, elasticity

and cartilage support of the trachea, it is difficult to in-

jure. Tracheobronchial injuries may occur in varying

degrees and in different localizations from a simple tear

to total rupture [2]. The “fallen lung” sign may be ra-

diologically observed in total bronchial ruptures. Com-

puted tomography has proved to be beneficial in the de-

tection of pathologies in patients with thoracic trauma [3].

In tracheobronchial injuries, the best diagnostic method

is bronchoscopy. Treatment is the primary repair of the

tracheobronchial tree with the preservation of pulmonary

tissue. In tracheobronchial injuries, delay or the oversight

of diagnosis can lead to death or potentially fatal com-

plications such as respiratory insufficiency, mediastinitis,

sepsis, airway stenosis, bronchiectasis, recurrent pulmo-

nary infections and premanent pulmonary dysfunction.

Tracheobronchial injuries are an important issue to be

discussed due to the high mortality rates, the difficulties

in diagnosis and the continuing controversy with regards

to treatment methods.

2. CASE REPORT

A 25-year-old male patient was admitted with the

complaints of hoarseness and swelling in the cervical

region following a blunt cervical and thoracic trauma due

to an in-vehicle traffic accident. The Patient had no his-

tory of any disease. On admission, the patient was con-

scious, in good general condition, oriented, cooperative

and his Glasgow Coma Scale score was 15. His blood

pressure was 118/75 mmHg, RR was 18/min, heart rate

was 76 bpm and SO2 was 84%. On inspection, there

were superficial abrasions and lacerations of 2 cm on the

frontal midline region and of 1 cm on the dorsal aspect of

the nose and a swelling on the anterior of the neck. Res-

piratory sounds were equal in both hemithorax. On pal-

pation, there were crepitations consistent with subcuta-

neous emphysema in the anterior aspect of the neck.

Respiratory sounds were normal on auscultation. Other

systemic examinations were normal. With intravenous

contrasted cervical tomography, extensive air densities

were observed in the skin and subcutaneous soft tissues

H. Kara et al. / Case Reports in Clinical Medicine 2 (2013) 502-504 503

in the paratracheal and retropharyngeal regions and an

image consistent with tracheal rupture was observed at

the level of the 7th cervical vertebra and first thoracic

vertebra (Figures 1-3). On bronchoscopy, granulation

tissue at a 9 - 11 o’clock level, 1 - 2 cm distal to the vo-

cal cords and a covered rupture area were observed.

There was no air leakage at this point and the wound was

left for secondary recovery. The patient was hospitalized

at the Department of Thoracic Surgery for follow up and

treatment. The thorax tomography obtained a day later

revealed pneumomediastinum and subcutaneous emphy-

sema findings. The patient improved clinically and was

discharged 7 days later.

3. DISCUSSION

Thoracic traumas account for approximately 25% -

31% of all traumas. Tracheobronchial injury occurs in 1%

- 2% of blunt thoracic traumas [1,4]. In literature, various

information regarding the localization of tracheobronchial

injuries is available. While there are studies indicating

that injuries are most common in the trachea, some others

indicate that injuries are more common in the left bron-

chus and its branches. Injuries can be transverse, longitu-

dinal and complex [5,6]. In our blunt thoracic trauma case,

the tracheal rupture was located 1 - 2 cm distal of the vo-

cal cords.

Various mechanisms have been suggested for tracheo-

bronchial injuries. Hood et al. suggested that sudden chest

compression was the most important mechanism. With

rapid impact trauma, the antero-posterior diameter of the

thorax decreases and the transverse diameter increases.

With this effect, the lungs are separated from eachother

and bronchial rupture occurs due to the created tension

force at fixation points such as the carina and cricoid. In

addition, rupture may occur as the result of increased in-

trabronchial pressure due to the compression of the tra-

cheobronchial system between the sternum and coulumna

vertebralis [7]. Respiratory distress and subcutaneous

Figure 1. With intravenous contrasted cervical CT imaging.

White arrow; trachea, yellow arrow; tracheal rupture area, red

arrow; air density in the paratracheal area.

Figure 2. With intravenous contrasted cervical CT imaging.

White arrow; trachea, yellow arrow; tracheal rupture area, red

arrow; air density in the paratracheal area, green arrow; air

density in the subcutaneous soft tissues, blue arrow; air density

in the retrofarangial areas.

Figure 3. With intravenous contrasted cervical CT imaging.

White arrow; trachea, red arrow; air density in the paratracheal

area.

emphysema are the most common findings in patients

with tracheobronchial injury. In tracheobronchial ruptures,

mediastinal and cervical emphysema can be seen without

pneumothorax development if the mediastinal pleura is

durable [8,9]. Our patient had subcutaneous emphysema

without penumothorax. We associated the absence of res-

piratory distress with the perforation being partial and co-

vered.

Complications such as total rupture can occur in cases

with partial tracheal and bronchial rupture during intuba-

tion. In bronchial ruptures, intubation in the healthy side

of the bronchus should be performed with a double lumen

tube. Our patient did not require intubation.

In tracheobronchial injuries, definite diagnosis can be

made with bronchoscopy. However, 3-dimensional spiral

tomography is also important for diagnosis. Diagnosis is

difficult if the mediastinal pleura is intact. Bronchoscopy

H. Kara et al. / Case Reports in Clinical Medicine 2 (2013) 502-504

504

may give 20% - 40% false negative results and this ratio

increases if the bronchial injury is associated with other

organ injuries. Fiberoscopy is preferred in patients with

head-neck and cervical injuries. This also increases the

ratio of false negativity. So bronchoscopy should be re-

peated if the suspicion of rupture continues [5,8]. Our

patient had a nasal fracture in addition to the tracheal

rupture. On bronchoscopy, granulation tissue and covered

rupture site were observed at a 9 - 11 o’clock level, 1 - 2

cm distal to the vocal cords.

Treatment of tracheobronchial injuries is divided into

two methods: surgical and conservative. Care should be

taken to preserve lung parenchyma during operative pro-

cedures and bronchoscopic techniques should be per-

formed. Conservative treatment is sufficient if the bron-

choscopic trauma is at a perimeter less than 1/3 of the

trachea or bronchus, if air leakage is prevented with tube

drainage and if total lung expansion is obtained. Conser-

vative treatment methods include intubation, tracheo-

stomy and patient monitorization [8]. Our patient did not

have primary repair. The wound was left to recover sec-

ondary. Secondary repairs are required due to delays in

diagnosis in 17% - 27% of patients. Patients on average

apply to hospitals within 1 - 3 months. The lungs can be

expanded by a successful primary anastomosis even if

there is a delay in diagnosis and on average can become

functional at the end of 2 - 6 months [10,11]. In some

patients, stenosis may develop at the anastomosis site

following primary repair of the ruptured area. Endoscopic

dilation [bronchoscopic dilation, laser, cryotherapy, elec-

trocautery and stent implantation] may be performed in

patients who develop anastomotic stenosis [12].

In conclusion, the early diagnosis of tracheobronchial

ruptures, which may vary from simple tears to total rup-

tures and present with different clinical signs, is important.

Clinical evaluation and diagnostic tests should be per-

formed carefully and rapidly. Tracheobronchial rupture

should be suspected in all patients who have massive air

leakage after blunt thoracic trauma, mediastinal or subcu-

taneous emphysema with penumothorax and non-ex-

pansed lungs. Bronchoscopic evaluation should only be

performed under conditions where emergency surgery can

be performed. This life-threatening condition may be

controlled with intubation or tracheostomy. In addition,

care should be taken on the follow-ups after discharge in

patients with thoracic trauma and intervals should be fre-

quent within the first 3 months after trauma. Thus, the

injuries overlooked on the initial assessment may be rec-

ognized at a later period.

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